Superior Thyroid Research Articles

Turned in fasciocutaneous island flap from face and neck based on subdermal microcirculation for reconstruction of the oral cavity following cancer surgery.

Background:The skin and soft tissues of the face and neck have a rich plexus of dermal-subdermal vessels, which creates the possibility of raising a fasciocutaneous flap based on this vascular supply. A turned in fasciocutaneous island flap (TIFCIF) from an adjacent area of the defect can provide a simple substitute to many complex reconstructive procedures.Materials and Methods:Fifteen patients underwent wide excision for oral cancer and upper neck dissection, maintaining bone framework, between August 2010 and June 2014. The reconstruction was done with a ’turned in fasciocutaneous island flap’ (TIFCIF) from the upper neck-lower face based on subdermal superficial adipofascial microvascular network instead of a specific known feeder vessel. The upper cervical flap, the donor site, when raised during the initial incision and the upper neck dissection, was cut off from the facial artery, the submental artery, the superior thyroid and the transverse cervical arteries. The microcirculation depended largely on the rich vascular plexus formed of the branches of the superficial temporal and the maxillary arteries. The donor site was primarily closed in Fourteen of the Fifteen patients. Eight patients received post-surgery irradiation.Results:All the flaps survived and healed and withstood radiation well. Two patients had flap dehiscence from suture line, of which one needed reattachment while other a minor one healed by itself and one patient had occasional drooling. There was no difficulty in eating or swallowing.Conclusions:A random patterned TIFCIF based on superficial subdermal adipofascial microcirculation, formed of a rich vascular plexus in the face and neck region can provide a simple alternative for intraoral reconstruction.

Management and prevention of acute bleedings in the head and neck area with interventional radiology.

BackgroundThe Interventional Neuroradiology is becoming more important in the interdisciplinary treatment of acute haemorrhages due to vascular erosion and vascular tumors in the head and neck area. The authors report on acute extracranial haemorrhage in emergency situations but also on preventive embolization of good vascularized tumors preoperatively and their outcome.MethodsRetrospective analysis of 52 patients, who underwent an interdisciplinary approach of the ORL Department and the Interventional Neuroradiology over 5 ½ years at the Department of Otorhinolaryngology, Klinikum Rechts der Isar, Technical University of Munich, Germany. Their outcome was analysed in terms of success of the embolization, blood loss, survival rate and treatment failures.Results39/52 patients were treated for acute haemorrhage. Twenty-five of them attributable to vascular erosion in case of malignant tumors. Affected vessels were the common carotid artery as well as its internal and external parts with branches like the ascending pharyngeal, the facial and the superior thyroid artery.Altogether 27/52 patients were treated for malignant tumors, 25/52 were attributable to acute haemorrhage due to epistaxis, after tonsillectomy, benign tumors and bleeding attributable to inflammations. Treatment of all patients consisted either of an unsuccessful approach via exposure, package of the bleeding, electrocoagulation or surgical ligature followed by embolization or the primary treatment via interventional embolization/stenting.ConclusionsThe common monitoring of patients at the ORL and interventional neuroradiology is an important alternative especially in the treatment of severe acute haemorrhage, following vascular erosion in malignant tumors or benign diseases. But also the preoperative embolization of good vascularized tumors must be taken into account to prevent severe blood loss or acute intraoperative bleeding.

Variations in the origin of superior laryngeal artery.

The superior laryngeal artery is the principal artery supplying the laryngeal mucosa, musculature, and glands. Knowledge of variations in the origin of superior laryngeal artery could prove to be very useful during reconstructive surgeries of the larynx, partial laryngectomy, laryngeal transplantation, and also during procedures like super-selective intra-arterial chemotherapy for laryngeal and hypolaryngeal cancers. However, relatively few studies have been done on the superior laryngeal artery in comparison to its clinical importance. The present study was aimed at documenting the prevalence of variable origin of the superior laryngeal artery within the carotid triangle. Sixty hemi-necks obtained from 30 South Indian cadavers were dissected and studied for variations in the origin of superior laryngeal artery. It was observed that the superior laryngeal artery took origin from superior thyroid in 91.7% cases. Variable origin from the external carotid artery was noted in 5% cases. The superior laryngeal artery was found to arise from the lingual artery in one case alone (1.7%). In addition to the above findings, a very rare variation of superior laryngeal artery arising from the ascending pharyngeal (1.7%) was also observed in the hemi-neck of one cadaver. All the variations that were observed were unilateral and on the left side. These findings may help provide further insight to the anatomists, radiologists and surgeons and can help improve performances during surgical manipulations of the larynx.

Superior and inferior thyroid artery: Branching pattern and anastomoses

Superior and inferior thyroid artery: Branching pattern and anastomoses

Intravital live cell triggered imaging system reveals monocyte patrolling and macrophage migration in atherosclerotic arteries

Intravital multiphoton imaging of arteries is technically challenging because the artery expands with every heartbeat, causing severe motion artifacts. To study leukocyte activity in atherosclerosis, we developed the intravital live cell triggered imaging system (ILTIS). This system implements cardiac triggered acquisition as well as frame selection and image registration algorithms to produce stable movies of myeloid cell movement in atherosclerotic arteries in live mice. To minimize tissue damage, no mechanical stabilization is used and the artery is allowed to expand freely. ILTIS performs multicolor high frame-rate two-dimensional imaging and full-thickness three-dimensional imaging of beating arteries in live mice. The external carotid artery and its branches (superior thyroid and ascending pharyngeal arteries) were developed as a surgically accessible and reliable model of atherosclerosis. We use ILTIS to demonstrate Cx3cr1GFP monocytes patrolling the lumen of atherosclerotic arteries. Additionally, we developed a new reporter mouse (Apoe−/−Cx3cr1GFP/+Cd11cYFP) to image GFP+ and GFP+YFP + macrophages “dancing on the spot” and YFP+ macrophages migrating within intimal plaque. ILTIS will be helpful to answer pertinent open questions in the field, including monocyte recruitment and transmigration, macrophage and dendritic cell activity, and motion of other immune cells.

Correlation between Colour Duplex and Technetium-99m Thyroid Scan in Identifying the Cause of Toxic Goitre

Introduction: Differentiation between thyroiditis induced thyrotoxicosis and Graves' disease is important for selection of proper therapy. It is often difficult to make this distinction without performing thyroid scintigraphy. Color flow Doppler sonography (CFDS) is gaining importance for the functional evaluation of the thyroid disorders. We aimed to determine the value of CFDS for the etiological diagnosis of thyrotoxicosis. Patients and methods: Thirty patients with clinical and lab signs of hyperthyroidism (12 Graves' disease and, 18 patients with Hashimoto's thyroiditis) with 10 euthyroid controls were evaluated.Etiological diagnosis was carried out using standard methods. Conventional grey scale sonography was done, followed by CFDS. Doppler patterns of the glands were scored and peak systolic velocity (PSV) measurements were obtained from superior and inferior thyroid arteries. Results were correlated to isotope scanning which was used as a golden standard. Results: Vascular patterns were significantly more prominent, and the mean PSV values were significantly higher in the Graves' Disease patients compared to the thyroiditis patients than controls. CFDS could differentiate the untreated Graves' Disease from the thyroiditis which had similar grey scale findings but higher vascular patterns and significantly higher PSV values, sensitivity = 96.6%, specificity= 96.6 %, and P>0.001 Conclusion: As an inexpensive, fast, and noninvasive imaging procedure, CFDS could be helpful in the initial clinical evaluation and may avoid scintigraphy in a substantial number of thyrotoxic patients.

Educational Exhibit Abstract No. 374 - Parathyroid venous sampling: a review of the technique and its utility in localizing parathyroid adenoma

Learning Objectives To discuss the technique of venous catheterization and sampling for localization of parathyroid adenoma. To determine the relevance of parathyroid venous sampling at our institution by performing a retrospective analysis of 29 patients over a 6 year period. Background Selective thyroid venous catheterization and detection of a venous PTH gradient allow for lateralization of parathyroid adenoma. Because of the rare instances that the inferior thyroid vein is not the major venous drainage route, our institution samples multiple other regional veins, to ensure that, if present, a PTH gradient is detected. Clinical Findings/Procedure Details Patients are referred by a single surgeon to a single interventional radiologist for parathyroid venous sampling. Venous samples for intact parathyroid hormone are obtained from multiple veins including: superior thyroid, internal jugular, innominate, inferior thyroid, thymic (if identified), left superior intercostal, SVC (above and below azygos vein), right hepatic, IVC, and bilateral iliac. Results from 29 patients, over a 6 year period, demonstrate that parathyroid venous sampling alone, or in conjunction with 4-D Neck CT, is effective for pre-surgical lateralization of parathyroid adenoma. Conclusion and/or Teaching Points Although an uncommon procedure, it is important to understand the technique and application of parathyroid venous sampling. The procedure is successful at localizing parathyroid adenomas pre-operatively, resulting in shorter operating room times and reduced patient morbidity.

Intrathyroidal parathyroid carcinoma: report of an unusual case and review of the literature.

Intrathyroidal parathyroid carcinoma is an exceedingly rare cause of primary hyperparathyroidism. A 51-year-old African American female presented with goiter, hyperparathyroidism, and symptomatic hypercalcemia. Sestamibi scan revealed diffuse activity within an enlarged thyroid gland with uptake in the right thyroid lobe suggestive of hyperfunctioning parathyroid tissue. The patient underwent thyroidectomy and parathyroidectomy. At exploration, a 2.0 cm nodule in the usual location of the right inferior parathyroid was sent for intraoperative frozen consultation, which revealed only ectopic thyroid tissue. No parathyroid glands were identified grossly on the external aspect of the thyroid. Interestingly, postoperative parathyroid hormone levels normalized after removal of the thyroid gland. Examination of the thyroidectomy specimen revealed a 1.4 cm parathyroid nodule located within the parenchyma of the right superior thyroid, with capsular and vascular invasion and local infiltration into surrounding thyroid tissue. We present only the eighth reported case of intrathyroidal parathyroid carcinoma and review the literature.

Anatomical study of the external carotid artery and its branches for administration of superselective intra-arterial chemotherapy via the superficial temporal artery

The branching patterns of the external carotid artery vary among individuals, and consideration of the proximity of nerves is important during catheter insertion in superselective intra-arterial infusion via the superficial temporal artery. We aimed to evaluate the anatomy of the external carotid artery and its surrounding nerves for safe and accurate administration of superselective intra-arterial chemotherapy via the superficial temporal artery. We analyzed the external carotid artery and its branches morphometrically in 28 Japanese cadavers (56 sides). Vascular tortuosity in the preauricular region of the catheter insertion site was observed in 42.9% of the sides; the main trunk of the external carotid artery was excessively tortuous in 25.0% of the sides, primarily in the preparotid region. Faciolingual and superior thyrolingual trunks were observed in 28.6 and 1.8% of the sides, respectively. The superior thyroid, lingual, facial, occipital, and maxillary arteries branched from the external carotid artery above the carotid bifurcation in 41.1% of the sides. The mean distance between the insertion site and maxillary artery was 39.5 mm, indicating the extent of catheter insertion. The auriculotemporal nerve was observed near the superficial temporal artery in the preauricular region in 44.6% of the sides; however, the clearly identifiable nerves in the exposed area were difficult to avoid. Because of the branching variations observed in individuals and sides, preoperative angiography is extremely important for avoiding complications.

Variation in the branching pattern of the four major caudal vessels emerging from the external carotid artery

The branching pattern of vessels emerging from the external carotid artery (ECA) displays considerable variation. Knowledge of these variations is of particular interest to clinicians. Surprisingly, there are few reports in the literature assessing these differences with regard to gender and sidedness (i.e., branching patterns of the right vs. left neck). The objective of the current study was to assess the origin of the four primary caudal branches of the external carotid artery: the superior thyroid (STA), lingual (LA), facial (FA), and occipital (OA) arteries with regard to gender and side. Seventy‐three cadavers (35 male, 38 female) were studied (65 right necks, 62 left necks). We observed that the STA on the right side emerged from the ECA more frequently than it did from the common carotid artery (CCA) (28 and 20, respectively), however, on the left side, the STA emerged more frequently from the CCA than the ECA (34 and 19, respectively). We observed the LA and FA to arise individually more frequently than from a common trunk (right 72%, left 81%). We observed that the OA emerged below the origin of the FA more frequently than above (right 55%, left 64%). With regard to gender, branching pattern variation was similar for the vessels studied. We conclude that variation in the branching pattern is substantial regarding sidedness but not so regarding gender. This study was supported by the JMU Department of Biology.

An Algorithm for Recipient Vessel Selection in Microsurgical Head and Neck Reconstruction

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.

後頭動脈・上甲状腺動脈を利用した橈骨動脈グラフトバイパス術

The radial artery and saphenous vein have been used as a useful free graft for neurosurgical revascularization surgery. Potential disadvantages of the radial artery compared with the saphenous vein include relative shortness, spasm, and functional occlusion. To compensate for the short length of the radial artery graft, the radial artery and the superior thyroid or occipital arteries were connected end-to-end. This method was applied in 3 cases of unclippable aneurysms, achieving adequate revascularizations. There were no complications related to this procedure. Radial artery graft bypass using the superior thyroid or occipital artery is a simple, safe, and useful method for cerebral revascularization.

Analysis of Recipient Vessel for Microvascular Reconstruction of the Head and Neck

ResultsZZThe frequently used recipient artery included facial (66.4%), superior thyroid (17.8%), lingual (8.1%), transverse cervical (6.9%), and external carotid (0.8%). The recipient vein included facial (43.7%), external jugular (39.3%), superior thyroid (5.8%), anterior jugular (1.7%), and transverse cervical (0.7%). End-to-end venous anastomoses were completed in 230 flaps and end-to-side anastomoses in 14 flaps. Three patients had one end-to-end and one endto-side anastomoses. The interposition vein grafts were used in 3 cases. Dual venous anastomoses were performed in 48 cases and single anastomosis in 199 cases. Twenty-one (8.5%) cases of free flap compromise due to vascular obstruction were identified and 11 flaps were lost (4.5%) with an overall success rate of 95.5%. There was no relationship between free flap compromise and the choice of recipient artery (p=0.360) or vein (p=0.125), the method of venous anastomosis (p=0.683), the use of an interposition vein graft (p=0.595), and the number of venous anastomosis (p=0.076). ConclusionZZAll vessels in the head and neck are potentially suitable for microvascular anastomoses. Flap compromise was not related to the method of venous anastomosis, the interposition vein graft or the number of venous anastomosis. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:20-3 Key WordsZZHead and neck neoplasms·Surgical flaps·Blood vessels.

Double vascular anastomosis in the neck for reliable free jejunal transfer

To reduce the possibility of necrosis in free jejunal transfer after total pharyngolaryngo-oesophagectomy, we made a second set of arterial and venous anastomoses in addition to the usual cervical arterial and venous anastomoses. To obtain two different arterial flows (carotid and subclavian systems), the recipient arteries were the superior thyroid and the transverse cervical. For venous flow, the internal and external jugular veins were used. All flaps survived. This procedure, which is limited to the already dissected neck with no procedures in other areas, is less invasive than others. Its advantages are that when one vessel has thrombosed the other vessel functions as a safety valve, and the greater pliability of the vascular pedicles makes it easier to reach the recipient vessels. Because this method is theoretically safe and results in less possibility of losing a flap when the anastomosis is unreliable, the double-pedicled transfer can be an option for safer free jejunal transfer.

Evaluation of selective embolization of thyroid arteries (SETA) as a preresective treatment in selected cases of toxic goitre

Backgroundin recent years, an increasing interest in the application of selective embolization of thyroid arteries (SETA) in the treatment of thyroid diseases is observed. In the present report, we analyse the value, safety and possible indications for preresective SETA in cases of large toxic goitres.Patients and methodthe study group comprised 10 patients with large toxic goitre (thyroid volume 254 ± 50 mL), including one patient with cervicomediastinal goitre and one patient with anti-thyroid drug intolerance in state of overt thyrotoxicosis. All the patients underwent SETA of the superior and/or inferior thyroid arteries, followed by thyroidectomy, performed up to thirty-six hours after SETA (23.1 ± 11 h). After embolization, selective angiographies of thyroid arteries were performed to ensure that the targeted arteries had been completely occluded.Results and conclusionin all the patients, SETA decreased blood flow through the thyroid. Preresective SETA reduced blood loss during and after thyroidectomy and decreased the operating time, but the differences were too small to justify routine applications of preresective SETA as an adjunct to surgical treatment of toxic goitre. On the other hand, SETA is a safe and minimally-invasive technique, which may become an attractive option for quick preparation to surgery in selected patients with toxic goitre, who present anti-thyroid drug intolerance or refuse radioactive iodine treatment.

Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander

Resurfacing of facial massive soft tissue defect is a formidable challenge because of the unique character of the region and the limitation of well-matched donor site. In this report, we introduce a technique for using the prefabricated cervicothoracic skin flap for facial resurfacing, in an attempt to meet the principle of flap selection in face reconstructive surgery for matching the color and texture, large dimension, and thinner thickness (MLT) of the recipient. Eleven patients with massive facial scars underwent resurfacing procedures with prefabricated cervicothoracic flaps. The vasculature of the lateral thigh fascial flap, including the descending branch of the lateral femoral circumflex vessels and the surrounding muscle fascia, was used as the vascular carrier, and the pedicles of the fascial flap were anastomosed to either the superior thyroid or facial vessels in flap prefabrication. A tissue expander was placed beneath the fascial flap to enlarge the size and reduce the thickness of the flap. The average size of the harvested fascia flap was 6.5 x 11.7 cm. After a mean interval of 21.5 weeks, the expanders were filled to a mean volume of 1,685 ml. The sizes of the prefabricated skin flaps ranged from 12 x 15 cm to 15 x 32 cm. The prefabricated skin flaps were then transferred to the recipient site as pedicled flaps for facial resurfacing. All facial soft tissue defects were successfully covered by the flaps. The donor sites were primarily closed and healed without complications. Although varied degrees of venous congestion were developed after flap transfers, the marginal necrosis only occurred in two cases. The results in follow-up showed most resurfaced faces restored natural contour and regained emotional expression. MLT is the principle for flap selection in resurfacing of the massive facial soft tissue defect. Our experience in this series of patients demonstrated that the prefabricated cervicothoracic skin flap could be a reliable alternative tool for resurfacing of massive facial soft tissue defects. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Preoperative Embolization of Thyroid Arteries in a Patient with a Large Cervicomediastinal Hyperfunctioning Goiter

We present the case of a 61-year-old male patient with chronic obstructive pulmonary disease and a large cervicomediastinal multinodular hyperfunctioning goiter that made thyroidectomy a daunting task, especially considering the risk of intraoperative bleeding. The preoperative computed tomographic (CT) scan showed the right thyroid lobe very deeply rooted in the mediastinum, below the horizontal plane passing through the aortic arch. The thyroid mass imprinted the arterious and venous innominate trunks. To avoid a median sternotomy and remove the enlarged thyroid through a cervical approach alone, we decided to reduce the goiter in volume preoperatively by embolizing the thyroid arteries. We embolized the superior and inferior left, and the inferior right thyroid arteries. We spared the superior right thyroid artery because its blood supply contributed little to thyroid perfusion. After embolization, the patient was treated with antithyroid agents and corticosteroid drug therapy. At the same time, severe leukocytosis developed, thyroid hormone values increased, and a CT scan obtained 7 days after embolization showed the thyroid unchanged in volume. We therefore discharged the patient and were waiting for his laboratory blood chemical findings to return to normal. Thirty days later the patient was readmitted to hospital, and a new CT scan showed that the thyroid mass had diminished to half its initial volume. We could therefore perform a total thyroidectomy through a cervical approach alone. The only problem arose in dissecting tight right inferior laryngeal nerve adhesions to the thyroid capsule, probably sequelae of postembolization thyroiditis. Even though preoperative thyroid-artery embolization cannot be considered a routine technique in cervicomediastinal goiter surgery, in a rare patient who presents with a voluminous goiter such as the one we describe here, it is a useful procedure.

Arterial Supply of the Superior Cervical Ganglion in the Guinea‐Pig (Cavia porcellus)

The vascularization of the cranial cervical ganglion [superior cervical ganglion (SCG)] of 10 adult guinea-pigs (Cavia porcellus) was investigated by latex injection and dissection techniques. Compared with other species, there were differences in the arterial supply of SCG and in the number of branches originating from these vessels. The SCG received arterial blood from branches of the ascending pharyngeal and internal carotid arteries. In addition, it was demonstrated that the superior thyroid and occipital arteries contribute rarely to the vascularization of the SCG.

A rare anatomic variant: the lateral position of the external carotid artery

During educational dissections a rare anatomic variant was encountered at the level of the right carotid triangle of a human adult male specimen. The variant was unilateral. On that side the common carotid artery bifurcated slightly above the level of the upper border of the thyroid cartilage, but the external carotid artery was posterolateral to the internal carotid artery and the anterior branches of the external carotid artery (superior thyroid, lingual and facial arteries) initially crossed over the internal carotid artery before continuing with a normal anatomical course. The possibility of an inversed disposition of the internal and external carotid arteries must be held in mind when performing arterial ligatures in the carotid triangle, to avoid damage to the internal carotid artery or haemorrhagic accidents.

Is the Platysma Flap Musculocutaneous? Angiographic Study of the Platysma

The platysma flap has often been used for reconstructions of the head and neck, but the arterial anatomy of the platysma itself has not been clarified. The anterolateral neck skin in five sides of four fresh cadavers that had been injected systemically with a lead oxide-gelatin mixture was elevated and divided into three layers: the skin with adipofascial tissue over the platysma, the platysma, and the adipofascial tissue under the platysma. Radiographs were taken of each specimen using the soft x-ray system. The anterolateral neck skin was chiefly supplied by branches of the submental, facial, superior thyroid, transverse cervical, and occipital arteries, and it was found that the vasculature of the arterial branches can be classified into three groups. In all of the groups, the arterial branches penetrated the platysma and did not run long in the platysma layer. The platysma was supplied by only small vessels from the arterial branches. Furthermore, there was little connection between the vascular plexus of the platysma and that of the skin layer with adipofascial tissue above the platysma and the platysma located in the subcutaneous tissue. The platysma flap should be considered fasciocutaneous rather than musculocutaneous. Therefore, the platysma flap should usually be elevated with the deep adipofascial tissue under the platysma. Flap survival is threatened if it is elevated without the adipofascial tissue under the muscle as with a usual musculocutaneous flap.